Administrative Review Summary Report
Date: 12-18-24
Name of Agency: Legacy of Hope Foundation Date of off-site review: 08-06-24
Reviewer: Matthew Smith Date of on-site review: 09-19-24
and 10-10-24
Fiscal Action: No, the Performance Standard I violation was for a counting and claiming error resulting in an under claim for the review period.
Persons interviewed: Cindy Sullivan Date of exit conference: 12-13-24
Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program, and the School Breakfast Program.
The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):
· Civil Rights – Civil Rights Complaints Procedure: The written procedures for handling civil rights complaints did not contain the current USDA approved protected classes [as required by federal regulations 7 CFR Part 210.9 (b) (11) and 7 CFR Part 220.7 (e) (15) and USDA FNS Instruction 113-1]. Prior to the completion of the on-site portion of this AR, Legacy of Hope Foundation (LOHF) took corrective action by adopting a written procedure compliant with federal requirements.
· Civil Rights – Nondiscrimination Statement: At the time of the off-site visit LOHF was not using the current USDA approved nondiscrimination statement [as required by federal regulations 7 CFR Part 210.9 (b) (11) and 7 CFR Part 220.7 (e) (15) and USDA FNS Instruction 113-1]. Prior to the completion of the on-site portion of this AR, LOHF took corrective action and began using the current USDA approved nondiscrimination statement.
· Local Wellness Policy: The local wellness policy provided during the off-site portion of this AR did not contain the following required areas:
o Guidelines and standards for food and beverages served (not sold) during the school day [as required by federal regulation 7 CFR Part 210.31 (c) (2) and (3)].
o Designation of personnel responsible for ensuring the policy is implemented [as required by federal regulation 7 CFR Part 210.31 (e) (1)].
o Designation of personnel responsible for the assessment of the policy [as required by federal regulation 7 CFR Part 210.31 (e) (1)].
o The policy did not contain the same membership as was listed in the triennial wellness assessment report, federal regulations [7 CFR Part 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)] requires the local wellness policy committee to be listed.
Prior to the completion of the on-site portion of the AR, LOHF took corrective action by providing a policy compliant with federal requirements.
· Meal Patterns-Menu Week Assessment: During the breakfast and lunch menu week assessment for the week of 07/21/24 – 07/27/24, insufficient serving sizes were discovered for a couple of lunch menus served during the week [in violation of federal regulation 7 CFR Part 210.10 (c)]. These insufficient servings were non-systemic in nature. Prior to the on-site portion of this AR, LOHF took corrective action bringing the insufficient servings into compliance with the meal pattern. OKDHS School Nutrition Programs is exercising its discretion to not apply fiscal action as allowed for under federal regulation [7 CFR Part 210.18 (g) (2)].
· Multi-Site On-Site Self-Reviews: During school year 2023 – 2024, LOHF failed to complete the multi-site on-site self-reviews by February 1st. Prior to the opening of this AR, LOHF took corrective action by completing the self-reviews for each site and submitted documentation to OKDHS School Nutrition Programs.
· Non-Creditable Food Items Served as Part of A Reimbursable Meal: During the menu week assessment of breakfast and lunch menus (for the week of 07/21/24 – 07/27/24) non-creditable food products were served with lunch meals [in violation of federal regulation Appendix C to 7 CFR Part 210]. Prior to the completion of the on-site portion of this AR, LOHF replaced all the non-creditable food products with creditable food products.
· Whole Grain Rich (WGR) – Percentage of Weekly Serving Under 80%: During the assessment of breakfast and lunch menus for the week of 07/21/24 through 07/27/24 it was discovered the WGR percentage of the bread/grain component weekly serving for the breakfast menus was under 80% [Federal regulation 7 CFR Part 220.8 (c) (2) (iv) (B) requires at least 80% of the weekly serving be WGR]. Prior to the completion of the on-site portion of this AR, LOHF took corrective actions that brought the weekly percentage into compliance with the meal pattern requirement.
Prior to the completion of the on-site portion of this AR, LOHF took corrective action for the above findings. No further action is required for the above findings.
Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted August 6, 2024:
Professional Standards – Annual Training Requirements: During school year 2023 – 2024, one employee with part-time duties within the school food services program failed to complete at least four hours of training crediting toward annual training hour requirements as required by federal regulation [7 CFR Part 210.30 (e)].
To demonstrate compliance with annual training requirements:
· Review the training records for all employees with duties within LOHF’s school food services program to ensure each employee is on track with completing enough training hours crediting toward the annual training hours to be compliant with federal regulations [7 CFR Part 210.30 (c) and 7 CFR Part 210.30 (e)].
· Continue to track each employee with duties within LOHF’s school food services program progress toward becoming compliant with the annual training requirements for school year 2024 – 2025.
· Provide LOHF’s plan for corrective action to demonstrate compliance and understanding.
Professional Standards – Eight-Hour Food Safety Training: The new school food services director failed to complete eight hours of food safety training within 30 days of being hired, or within five years of assuming the duties of school food services director [as required by federal regulation 7 CFR Part 210.30 (b) (1) (v)].
To demonstrate compliance with the eight-hour food safety training requirement:
· Have the school food services director complete eight hours of food safety training.
· Provide documentation of the director’s completion of eight hours of food safety training.
· Submit the above documentation, as well as LOHF’s plan for corrective action to demonstrate compliance and understanding.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted September 19, 2024, and October 10, 2024:
Counting and Claiming: A review of the counting and claiming system identified a claiming error for the review period (July 2024), which is a Performance Standard I (PSI) Violation [per federal regulation 7 CFR Part 210.18 (g) (1) (ii)]. The error was determined to be non-systemic and was only found with the review period’s lunch.
The counting and claiming error appear to have occurred when the meal counts were reported to Oklahoma Human Services School Nutrition Programs (OKDHS SNP). The error resulted an under claim of one lunch meal.
Below are the differences OKDHS SNP has identified in LOHF lunch meal counts claimed for July 2024:
|
OKHS SNP Count |
LOHF Meal Roster Count |
LOHF Claim |
Difference |
Free |
960 |
960 |
959 |
-1 |
Free lunches meals were under claimed by one meal.
Federal regulation [7 CFR Part 2108 (a) (2)] requires each SFA to review their claims for accuracy prior to submitting them to the State Agency (SA).
To demonstrate compliance with counting and claiming requirements:
- Review the counting and claiming system and create a plan to ensure accurate meal counts are claimed.
- Complete the edit check process for breakfast and lunch meals daily.
- Provide copies of the of the following: meal rosters for December 2024 for breakfast and lunch, as well as the edit checks for breakfast and lunch for December 2024.
- Provide the above along with LOHF’s plan for corrective action to demonstrate compliance and understanding.
Counting and Claiming – Edit Checks: The Intensive Treatment Service (ITS) site did not conduct Lunch or Breakfast edit checks during the review period (July 20224) as required by federal regulations [7 CFR Part 210.8 (a) (3) and 7 CFR Part 220.11 (d)].
Carter Hall’s review period the edit checks were also not properly conducted as required by federal regulations [7 CFR Part 210.8 (a) (3) and 7 CFR Part 220.11 (d)]. The daily attendance was not being compared to the meal counts. The site was just confirming the daily meal counts.
To demonstrate compliance with edit check requirements:
· At the ITS site begin conducting daily edit checks for the NSLP and SBP.
· At the Cater Hall site provide training to the staff member(s) completing the daily edit check process for both the SBP and the NSLP.
· Be sure all LOHF sites are compliant with conducting daily edit checks for the NSLP and SBP.
· Provide the edit checks for December for the ITS site and the Cater Hall site.
· Provide the above documentation, as well as LOHF’s plan for corrective action to demonstrate compliance and understanding.
HACCP food safety Inspection: During school year 2023 – 2024, LOHF failed to request health inspections for their ITS site. Federal regulation [7 CFR Part 210.13 (b)] requires SFAs receive at least two health inspections during the school year. If two are not received, the SFA must call their local health department and request a second inspection. SFAs must document their local health department's response if they decline to conduct the second health inspection. This process must be conducted each school year, even if the local health department refuses to inspect a location.
To demonstrate compliance with health inspection requirements:
- Provide LOHF's corrective action plan to demonstrate understanding and compliance with health inspection requirements.
Reviewer’s Comments: I would like to take the opportunity to commend those involved with LOHF’s school food services program on a job well done. Keep up the good work.
Procurement Review Summary Report
Date: 12-18-24
Name of Agency: Legacy of Hope Foundation Date of AR off-site review: 08-06-24
Reviewer: Matthew Smith Date of AR on-site review: 09-19-24
and 10-10-24
Persons interviewed: Cindy Sullivan Date of exit conference: 12-
Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program (NSLP) and the School Breakfast Program (SBP).
The following areas were corrected during the Procurement Review (PR):
· Procurement Plan: At the time of the PR was commenced, Legacy of Hope Foundation (LOHF) provided a procurement plan failing to address the use of the micro-purchase method of procurement [2 CFR Part 200.318 (a)]. Prior to the completion of the off-site portion of the AR, LOHF took corrective action by adopting an amendment to their procurement plan addressing the use of the micro-purchase method of procurement.
No further action is required for the above.
Findings for the Procurement Review (PR)
Solicitation Document: The solicitation (specification) document provided at the time this review was commenced had a few issues causing non-compliance with federal regulations.
The first issue is the solicitation (specification) document did not contain sufficient detail for potential vendors to provide a response with products suitable for use in the NSLP and the SBP. The second issue was discovered during a review of invoices by OKDHS School Nutrition Programs. This review demonstrated items were purchased that were not on the solicitation document. Federal regulation [ 2 CFR Part 200.319 (a)] requires procurement transactions “…in a manner that provide full and open competition.” Providing more details, including all items to be procured, could cause potential vendors to respond differently to the solicitation.
The final issue with the solicitation document (specification document) is it did not contain “…language requiring the purchase of foods that meet the Buy American Provision requirements” as required by federal regulations [7 CFR Part 210.21 (d) (3) and 7 CFR Part 220.16 (d) (3)].
To demonstrate compliance with Buy American Provision requirements:
- Provide LOHF’s plan for corrective action to demonstrate understanding and compliance.
Record Keeping: During this review it was discovered LOHF did not retain documentation to adequately document the history of the procurement process specifically LOHF’s use of the small purchase method used during school year 2023 – 2024. Federal regulation [2 CFR Part 200.318 (i)] requires SFAs to “…maintain records sufficient to detail the history of each procurement transaction." This documentation must include but not limited to:
· Documentation demonstrating the solicitation document was communicated to potential vendors.
· Documentation of communication with potential vendors during the procurement process.
· Documentation of the responses from potential vendors.
· Documentation of the vendor selection process.
Documentation of the procurement process is required to be retained for three school years plus the current school year.
To demonstrate compliance with the record keeping requirements:
· Provide LOHF’s plan for corrective action to demonstrate understanding and compliance.
